Principles of Ethics - ONS

CHAPTER 1

Principles of Ethics

Amy M. Haddad, PhD, RN

Introduction

What kinds of acts are right in oncology nursing practice? This basic yet complex question is commonly asked by nurses in oncology and other specialties to determine what they should do in a specific case or how the entire profession should act regarding interactions with patients, families, and colleagues. General ethical principles often are used as guides for right action. The first such contemporary example that proposed principles as guides in a health-related area was the Belmont Report (National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, 1979), which identified the principles of respect for persons, beneficence, and justice in human subjects research. In 1981, Beauchamp and Childress built on this work and applied it to health care in the first edition of their book Principles of Biomedical Ethics, now in its seventh edition (Beauchamp & Childress, 2012). They proposed four key principles: respect for autonomy, beneficence (the obligation to do good), nonmaleficence (the duty not to harm), and justice. Others in bioethics have suggested additional derivative principles, including veracity (the obligation to tell the truth), fidelity (the duty to keep promises), and avoidance of killing (Veatch, Haddad, & English, 2010).

Although helpful in illuminating shared values and important ethical norms in health care, the principlist approach to ethics is not without its problems and critics. For example, polarities and problems exist within the principles themselves, such as tensions between present versus future expressions of autonomy (Collopy, 1988) or disagreement regarding who is best suited to determine benefit (Childress, 1982). Conflicts can also arise between principles, such as when one is attempting to fulfill the demands of respect for autonomy, which can run counter to the health professional's obligation to avoid harm. Additionally, no one principle of the four is given primacy, so determining which principle carries the day in

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2 | Ethics in Oncology Nursing

a specific case is difficult. Critics have noted that the universal, objective nature of principlism seems to ignore the specific context of an ethical action, which they consider to be an integral component of moral decision making and reflection (Clouser & Gert, 1990; Jecker & Reich, 1995). Even with these criticisms and problems, principlism is the most commonly used approach in healthcare settings and, therefore, is an important part of ethical deliberations.

The focus of this chapter is to provide an introduction to the contributions of ethical principles to oncology nursing practice as well as their limitations. Emphasis is placed on the word introduction, as the discipline of ethics is complicated and what may at first appear to be a clear application to practice often has hidden difficulties. A helpful metaphor for the discussion of principles and other components of ethics is to think about what happens when a flashlight shines in a darkened room. A flashlight highlights wherever its beam falls and obscures everything else in the room. The flashlight also causes us to see things in a different, heightened way than we would under normal lighting (Dougherty, Edwards, & Haddad, 1990).

Principles and other elements of ethics often work in a similar way. Principles can illuminate realities and relationships that we might not have noticed otherwise, but they can also de-emphasize other equally important components of ethics. To help provide a more complete picture of what is involved in ethics, the selected case study aims to not only highlight where traditional ethical principles are at play in oncology nursing practice but also to enhance understanding of ways to approach ethical concerns.

Basic Principles of Ethics

Ethics is the branch of philosophy that explores moral duty, values, and character. In effect, ethics involves the study of right and wrong, moral responsibilities of actors, individual/institutional/societal moral conduct, promises, rules, principles, and theories. The study of ethics can also involve the moral value of relationships and other contextual issues, such as power structures and sources of knowledge. Together, these constitute important concerns in contemporary ethics. As noted, there are several approaches to ethics, but the one that is most relevant to an exploration of ethical principles is normative ethics. "Normative ethics raises the question of what is right or what ought to be done in a situation that calls for a moral decision. It examines individual rights and obligations as well as the common good" (Davis, Aroskar, Liaschenko, & Drought, 1997, p. 2).

This chapter will examine the relationship of principles to ethical situations in oncology nursing. However, the moral life is more than merely making discrete decisions to do this or not do that but rather encompasses how people live and think about these matters and, perhaps more importantly, how people work with others to discern the course of action. Therefore, reflection and discussion about

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Chapter 1. Principles of Ethics | 3

ethical actions is also necessary for a fuller understanding of what acts are right. How nurses live the practice of and think about oncology nursing is particularly important because of the often life-threatening and always life-altering nature of cancer. Even in cases where cancer becomes a chronic condition with years of remission and recurrence, the nature of a cancer diagnosis often places the oncology nurse in complex ethical situations.

A brief, overarching explanation of the principlism of Beauchamp and Childress (2012) in their now classic Principles of Biomedical Ethics is in order before turning to specific principles. Beauchamp and Childress (2012) proposed a methodology to resolve ethical problems that is universally applicable in healthcare settings. As described by Viafora (1999), "Principlism relies upon a core of fundamental principles--themselves based upon some general theory--to be applied to rules which function as action-guides" (p. 285).

Therefore, the principles serve as a framework, and health professionals provide the "facts" of the situation or case in question, which when fed into the framework should ideally provide answers or, at minimum, insight into morally correct options.

Principles are based on more general theories. It is helpful to distinguish which theories support which principles. By shining a light on the theory, one can see the differences between principles that are oriented to consequences of actions and those that assert that the rightness or wrongness of an act is inherent in the act itself. The theoretical approach to ethics that focuses on outcomes is often referred to as the consequentialist view. A consequentialist deems actions as morally correct when they promote good. In other words, one should choose the action that brings about the most good, or, if there is little chance for a good outcome, the action that yields the least harm. An example of consequentialism in health care is the Hippocratic tradition in medicine that is based on the promotion of good for patients to the exclusion of other goods (Edelstein, 1987). Emphasis on the primacy of patient benefit is also evident in the American Nurses Association's (ANA's) Code of Ethics for Nurses, which states, "The nurse's primary commitment is to the recipients of nursing and healthcare services-- patient or client--whether individuals, families, groups, communities, or populations" (ANA, 2015, p. 5). There are, of course, more complicated theoretical models of consequentialism, but this basic definition will suffice for this introductory chapter. Principles that derive from a consequentialist perspective are beneficence and nonmaleficence, two of the foundational principles proposed by Beauchamp and Childress (2012). Even without a background in philosophy, almost all health professionals would acknowledge the duty or obligation to do good for patients and to avoid as much harm as possible. Although the two principles can, and some would argue should, be discussed separately, they often are intertwined in clinical practice. One distinction between the two principles is that nonmaleficence is an absolute moral duty in that one is always obligated to avoid harming others. The principle of beneficence, however, is almost an imperative in health care in that it implies that one should promote good but not to the same degree

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4 | Ethics in Oncology Nursing

in every case. Beneficence, therefore, is a relative duty in that the obligation to do good for others is tempered by other factors, such as the relationship held by those involved.

Nonmaleficence The obligation not to harm others would seem to take priority over most

other ethical principles. Beauchamp and Childress (2012) noted the connection between the principle of nonmaleficence and beneficence but resisted the idea of a hierarchal ordering of the two principles. They proposed the following norms:

Nonmaleficence 1. One ought not to inflict evil or harm. Beneficence 1. One ought to prevent evil or harm. 2. One ought to remove evil or harm. 3. One ought to do or promote good.

Each of the three principles of beneficence requires taking action by helping--preventing harm, removing harm, and promoting good--whereas nonmaleficence requires only intentionally refraining from actions that cause harm. Rules of nonmaleficence therefore take the form "Do not do X." (Beauchamp & Childress, 2012, p. 152) Some rules, such as "Do not lie to a patient" or "Do not harm one patient to benefit another," conform to the aims of nonmaleficence. However, as with most clinical situations, the rule of not harming is not as clear when applied to clinical practice. For example, a patient with metastatic cancer develops a bowel obstruction that appears to be due to benign strictures from previous surgery. Surgical intervention is indicated to correct the bowel obstruction, but, given the patient's cancer stage and general physical condition, the treatment team is divided regarding whether surgery in this case is a benefit or a harm. As with any surgical procedure, there are inherent risks and, given the patient's health status, the long-term benefits from surgery seem small in comparison. The short-term benefits of surgery, though, may loom large for the patient because of the nausea and acute pain that accompany bowel obstruction. There are also immediate life-threatening implications, such as ischemia of the bowel, that could be weighed differently by the patient and the surgical team. Thus, defining harm in order to avoid it is a more nuanced task than it first appears. Clinical parameters, patient and health professional values, and the relative balance between harms and benefits all play a part in determining harm.

Beneficence The duty to do good is a strong one in health care. Whether informed by

a religious tradition or basic human concern for the well-being of others, the

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Chapter 1. Principles of Ethics | 5

directive to "love thy neighbor" underlies the actions of health professionals. Although we may be called to "love one another" in the broadest sense, it is clear that our capacity to love is limited by many things, including lack of time, knowledge, or resources. So, beneficence, the duty to do good, is limited, and we must choose among limited options to determine where we can do the most good (Glaser, 1994).

In the delivery of oncology nursing care, all of the nurse's actions are directed toward the good of the patient in whatever way "good" is defined. Beneficence is demonstrated in the smallest of actions and interactions with the patient, from a comforting touch to attentive listening. In addition, the principle of beneficence requires respect for the wishes and choices of the patient or family because such choices reflect interpretation of the good or what is of benefit. The nurse also has a privileged perspective on decisions and outcomes because of advanced education and experience. In contrast, the patient may be at a disadvantage when making decisions because of lack of healthcare knowledge and the additional stressors of illness. This is where other ethical principles come into play, such as respect for autonomy and the derived principle of consent that bolsters the patient's ability to make informed decisions. Beyond ensuring that patients have adequate information to determine the good and bad outcomes of actions, there can be differences in how the good is interpreted. For example, pain management would seem to be an uncontested good in patient care. However, the experience of pain and pain tolerance is highly subjective. Some patients may insist on the complete elimination of pain, whereas others may tolerate more pain to maintain a greater degree of consciousness. Patients may attach religious or redemptive meaning to pain that will alter how they consider the benefits and harms of pain relief. What may seem like a straightforward "good" in oncology nursing (i.e., relieving pain) is complicated in clinical practice. Discerning benefit should be an ongoing, collaborative process between the patient and family and the nurse. Balancing goods and harms as a broader principle is sometimes referred to as proportionality and will be discussed later in this chapter.

Respect for Autonomy Some principles are based on the inherent rightness or wrongness of an action

rather than the consequences of the action. "These positions, collectively known as formalism or deontologism, hold that right- and wrong-making characteristics may be independent of consequences, that morality is a matter of duty rather than merely evaluating consequences" (Veatch et al., 2010, p. 11). The duty to respect autonomy is one of these principles. The concept of respect for autonomy is based on a more fundamental principle of respect for persons. Respect for persons requires that individuals treat each other with respect regardless of conditions such as status, age, race, decision-making capacity, and so on. People are obligated to respect others merely because they are human. People are not, however, obligated to respect any and all actions of others, which is an important distinction.

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6 | Ethics in Oncology Nursing

If people are duty-bound to respect others, it follows that people should also respect their ability to make choices about how they will live their lives. The most fundamental aspect of respect for autonomy is the notion of noninterference with others. In a world of strangers, this idea of leaving others free to carry out their daily lives and business makes sense. Noninterference in healthcare relationships, however, does not make as much sense because health professionals are essentially asked to "interfere" with deeply personal facets of a person's life in order to cure, heal, and comfort.

Where autonomy plays a larger role in healthcare interactions is respect for self-determination, or being one's own person and making decisions about one's own well-being. Autonomy reflects a person's ability to express needs and control decisions. Whenever a person is ill, autonomy can be threatened. Patients with cancer need to make decisions about many aspects of their care, including whether to pursue standard or experimental treatment, which requires a higher level of informed consent. Because no one is capable of being completely or fully autonomous, acceptance occurs along a range of substantially autonomous decision making in which a person has "enough" understanding, information, and freedom to come to a sound decision in a particular context (Beauchamp & Childress, 2012). The amount of understanding, information, and freedom will vary from person to person and within the same person over time because of illness or injury. Determining whether a decision or action is substantially autonomous is important because of the obligation to honor autonomous actions even if the decision could lead to harm.

Justice The principle of justice addresses the proper distribution of benefits and bur-

dens. The allocation of healthcare resources is an abiding problem in health care. Oncology nursing is no exception. Distribution of resources can occur on various levels, from societal to personal. Justice also embodies the ideal of fairness. When one thinks of what is fair or just in a situation, he or she usually thinks about claims between people and rules to help mediate such claims. Consider the following example: Three patients arrive at the same time for their chemotherapy treatment at an ambulatory oncology clinic. One patient has arrived early for her appointment because she wants to talk to the nurse about a list of side effects and possible homeopathic remedies. The second patient is very weak and seems somewhat short of breath. The third patient is here for his final round of treatment and currently has few complaints. The nurse notes that all the other clinic nurses are busy, so she cannot delegate to a peer. She must decide which patient will get her initial attention. In order to make such a decision, the nurse is relying on principles of justice. The nurse could decide to spend her time with the patient where her actions will do the most good. Or, she could decide to direct her attention to the patient in the greatest need. Determining the distribution of healthcare resources, whether they be nurs-

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Chapter 1. Principles of Ethics | 7

ing time, access to diagnostic tests, or expensive medication, is one of the most complicated ethical problems in health care today.

Three additional principles deserve mention because of their importance in clinical practice: truth telling, fidelity (promise keeping), and avoidance of killing. These three principles are duty-based in that the right-making characteristic of the principles are inherent in the principles themselves, not the consequences.

Truth Telling The principle of veracity, or truth telling, requires that healthcare providers be

honest in their interactions with patients. "Traditional ethics holds that it is simply wrong morally to lie to people, even if it is expedient to do so, even if a better outcome will come from the lie. According to this view, lying to people is morally wrong in that it shows lack of respect for them" (Veatch & Haddad, 2008, p. 102). Being honest with patients helps to build and maintain trusting relationships that are essential to the delivery of quality patient care. However, as with the other principles, telling the truth to a patient is not always viewed as the right thing to do. Although mainstream American culture holds honesty in high regard, other cultures do not. In fact, telling sick and dying people about their conditions, particularly in the case of terminal illness, can be seen as cruel and even harmful by certain ethnic and racial groups (Blackhall, Frank, Murphy, & Michel, 2001). The principle of truth telling is influenced, interpreted, and valued differently because of the backgrounds, education, and socioeconomic status of providers and patients.

Fidelity Moral theologian Paul Ramsey maintained that the fundamental question in

healthcare ethics relates to the principle of fidelity. We are born within covenants of life with life. By nature, choice, or need we live with our fellowmen in roles or relations. Therefore we must ask, what is the meaning of the faithfulness of one human being to another in every one of these relations? This is the ethical question. (Ramsey, 2002, p. xlv)

Fidelity is rooted in respect for persons and truth telling. Faithfulness to promises is important in relationships because it indicates the level of esteem held for one another and establishes trust. When a person makes a promise, he or she creates expectations of another. The person expects to rely on the promise and have a valid claim that it will be kept. When a nurse assures a patient that he or she will receive appropriate symptom management while undergoing chemotherapy, the message does not have meaning unless the nurse follows through on that promise when it is actually needed during treatment. Fidelity is also important in interactions with peers on the healthcare team. Generally, promises to peers are not explicit but are shown through actions that implicit promises are being

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8 | Ethics in Oncology Nursing

kept regarding important aspects of working together, such as honesty, not taking advantage of each other, and demonstrating dependability to be there for help and assistance when needed.

Avoidance of Killing Although the principle of nonmaleficence would seem to prohibit active

killing, some ethicists have argued that the seriousness and finality of killing requires a separate principle that specifically recognizes the prohibition (Veatch, 1981). Active killing can be deemed wrong from consequentialist (great and irreversible harm occurs) and duty-based (violates autonomy) perspectives. However, there are instances when killing could be justified, such as during war or in self-defense. There are also instances in which a person could consent to killing, as is the case with assisted suicide or voluntary euthanasia. Even with consent and the backing of law, as is the case in the states of Montana, Washington, Oregon, Vermont, and California, traditional religious and secular ethics has held to a prohibition of killing, even for merciful reasons. Patient requests to hasten death occurred frequently enough in oncology nursing practice that the Oncology Nursing Society (ONS) developed a position statement on hastening death. In the position statement, ONS recognized the nurse's right "to refuse to be involved in the care of patients who choose hastened death as a course of action" in jurisdictions where it is legally sanctioned (ONS, 2010, p. 249). The position statement also indicates that as a professional organization, ONS does not support actions that hasten death. ANA (2013) held a similar view in its position statement on euthanasia, assisted suicide, and aid in dying. In 2011, the Hospice and Palliative Nurses Association (HPNA) issued a position, endorsed by ONS, that identified nurses' rights to "decide whether their own moral and ethical value system does or does not allow them to be involved in providing care to a patient who has made the choice to end his or her life through [assisted death]" (HPNA, 2011, p. 2).

Virtue and Care-Based Ethics

While principlism focuses on actions, the character of the actor and where the actor is situated are obscured. Once again, a brief overview of two other approaches to ethics, virtue and care-based, provides a fuller view of ethics. Virtue ethics spotlights moral character rather than actions, as the following summary description of the theory notes.

Virtue ethics starts instead with the insight that our actions, by and large, are not isolated decisions that we make, but arise from our character, the deeper complement of typical patterns of behavior that we exhibit, and the values that we hold. These character traits are not static, but are shaped and re-shaped con-

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